Submission & eligibility guidelines for compounds

Transcription

1 Submission & eligibility guidelines for compounds A compound is a product that a pharmacist must make by mixing two or more ingredients, and when they are combined, become a preparation that is not commercially available. A compound can be in the form of liquid, capsules, cream, ointment, IV bag, etc. Compounds are sometimes referred to as mixtures or extemporaneous mixtures. Submission rules Whenever possible, we require that you transmit compound claims using the DIN of the principle prescription-requiring ingredient in that compound (if applicable). This will ensure an online eligibility check of the DIN/PIN you have transmitted. An example would be hydrocortisone 1% cream and ketoconazole % cream, compounded in equal parts please transmit the compound with the ketoconazole cream DIN and the appropriate compound code. The ketoconazole cream is a prescription-requiring ingredient and is likely to be eligible on most plans, whereas the hydrocortisone cream is OTC and not eligible on most plans. If your compound contains no prescription-requiring ingredients, please transmit using one of the ingredient DINs. If you must use a general compound PIN (e.g , ) to submit a claim, we strongly recommend that you contact the TELUS Health Assure Claims Pharmacy Support Centre to confirm eligibility prior to submitting the claim. Duplicating a commercially available product If a compound mimics a commercially available product, the compound will not be covered. If the commercially available product is out of stock, a temporary exception may be granted to allow for the compounding of the product until the commercially available product is available. If you have any questions regarding compound eligibility contact the TELUS Health Assure Claims Pharmacy Support Centre at Unlisted compound codes 0 = Compounded topical cream = Compounded internal powder 1 = Compounded topical ointment = Compounded injection or infusion = Compounded external lotion 7 = Compounded eye/ear drop = Compounded internal use liquid 8 = Compounded suppository = Compounded external powder 9 = Other compound All compounds must be submitted with the correct corresponding unlisted compound code. There are some exceptions to this rule, e.g. Remicade, methadone. See Appendix for some common compounds that have special PINs and submission rules. Ineligible compounds A commercial product is available in the same strength The primary ingredient is not covered under the plan member s plan, i.e. OTC sinvestigational products Natural products Homeopathic products The product is for cosmetic use The product contains an ineligible base/ingredient (see lists below for ineligible drugs and ineligible bases) or is in an ineligible format. Ineligible Bases, Ingredients and Formats: The following chemicals/drugs/ formats (but not limited to those listed) are not eligible on any of our plans, even if combined with a prescription-requiring medication or with a product considered to be an eligible benefit.

2 Ineligible bases Benoquin Lustra (entire product line) Rosacure BioBase G Neostrata (entire product line) Solage Eldopaque Neutrogena (selected products) Solaquin Eldoquin Porecelana sunscreens (all product brands) glycolic acid Rejuva Ultraquin Glyquin Renova Viquin Kinerase retinol vitamin E cream La Roche-Posay (entire product line) Reversa (entire product line) Ineligible ingredients aminophylline in a topical base DNCB (dinitrochlorobenzene) minoxidil (any strength) ammoniated mercury Evening Primrose Oil Perio Plus arsenic finasteride (compounded) Peru Balsam azaleic acid (Used for Hair Loss) gentian violet pregnenolone benzoin tincture/friar s Balsam glycolic acid secretin bichloracetic acid histamine/caffeine (Procarin ) titanium dioxide coumarin hydroquinone triamcinolone (used for hair loss) DCP (diphencyprone/ diphencyclopropenone) kojic acid tri-iodo-l-thyronine topical DHEA (dehydroepiandrosterone) magnesium dicitratem vitamin K topically DMAE (dimethylaminoethinol) mandelic acid yohimbine DMPS (dimercaptopropanesulphonate) Mercurochrome DMSA (dimercaptosuccinic acid) methylcellulose EM Ineligible forms/formats Regardless of the drugs or chemicals added, compounds made into the following dosage forms (but not limited to those listed) are not eligible under all plans: gummies pre-filled syringes timed release products lollipops sustained release products troches lozenges slow release products An ineligible ingredient/base/form may be covered by individual cardholder by exception only. Please confirm with the TELUS Health Assure Claims Pharmacy Support Centre before submitting claims under these circumstances. Eligible compounds Compounds are eligible if the primary active ingredient is covered on the cardholder s plan. Important: Even though an eligible prescription requiring DIN/PIN may be accepted online, if it has been added to a compound containing an ineligible ingredient or base as listed below or is in an ineligible format, the compound will be deemed ineligible and charge backs will apply.

3 Reimbursement time guidelines for compounds TELUS Health receives inquiries from pharmacies regarding the allowable time charges that can be charged to TELUS Health when submitting compounds. Depending on the mixture preparation, please refer to the appropriate chart below when submitting claims. End Result Equals a Cream/Ointment/Lotion Preparation Powder to Liquid Suspension/Emulsion (Internal/External Use) Quantity Range Quantity Range 0 to 1 grams 1 to grams to 0 grams 1 to 100 grams 101 to 00 grams 01 to 00 grams 01 to 00 grams 01 to 00 grams min min 1 min 1 min min 1 min 1 min 1 min 1 min min 1 min 1 min 0 min 1 min min min 0 min min 0 to 1 grams/ 1 to grams/ to 0 grams/ 1 to 100 grams/ 101 to 00 grams/ 01 to 00 grams/ 01 to 00 grams/ 01 to 00 grams/ min min 1 min 1 min min 1 min 1 min 1 min 1 min min 1 min 1 min 0 min 1 min min min 0 min min

4 Liquid to Liquid Compounds Quantity Range 0 to to min min min min min min min min min Liquid to Liquid Injections or Reconstituted Liquid - Vials 1 min 1 min End Result Equals a Capsule Form The allowable time plus an additional min/100 capsules Reminder: Any compounded SR products are not covered. 1 min min 11 min Capsules/Tablets Compounded to Liquid Oral Suspension Quantity Range Up to 1 tabs /caps 1 min min 0 min Powder to Liquid Injection - Vials 1 min 1 min End Result Equals a Suppository Form The allowable time plus an additional 0 min/100 suppositories 1 min min 11 min Additional notes: Compounding Topical Syringes: We allow time charge per number of ingredients plus an additional min per syringe. Compounding IV preparations and Cassettes: We allow minutes per mini bag We allow minutes per 100 ml cassette We allow 1utes per 0 ml cassette Pump bags are priced the same as cassettes Methadose is not considered a compound and should not be submitted with an unlisted compound code and compounding time.

5 Provincial Compound Fee Guidelines Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New-Brunswick Nova Scotia Newfoundland Prince Edward Island North West Territories, Yukon and Nunavut Fees A compound time charge of a pre-established amount per minute, plus a regular Only a regular dispensing fee can be charged if the compound requires less than utes preparation time. If a compound requires more than utes preparation, a regular dispensing fee plus an addition pre-established amount per minute for each minute in excess of seven (7) minutes can be charged. A compound time charge based on usual and customary Compounding time is a flat rate of 1. times the usual and customary dispensing Compounding time is a flat rate of 1. times the usual and customary dispensing Compounding time is a flat rate of 1. times the usual and customary dispensing Compounding time is a flat rate of 1. times the usual and customary dispensing Compounding time is a flat rate of 1. times the usual and customary dispensing * All guidelines are subject to modifications based on a number of factors including the usual and customary practices in different provinces. Note: 1. Pharmacies in Atlantic Canada are not permitted to charge a regular dispensing fee on top of the compound fee.. In Ontario for provincial coordination of benefits (COB), TELUS Health follows ODB allowable time charges. If you have any questions on how to transmit a compound claim, or if you need to determine compound eligibility, please do not hesitate to contact the TELUS Health Assure Claims Pharmacy Support Centre. For compound verification for a plan member, you will be asked to provide the following information: Plan Member s name Plan Member s drug card information Plan Member s date of birth ALL compound ingredients with their strength (if applicable) and/or quantity AST If the compound is deemed eligible, the agent may provide you with a compound PIN to submit the claim. Please note that all claims for compounds are subject to review by the TELUS Health Audit Department. Any compound claims determined to be ineligible or submitted for compounding charges (time and/or charge per minute) in excess of ACCEPTED PHARMACY PRACTICE will be adjusted or charged back to the pharmacy.